Employee Communication - Form C-17
Employee Name: Click here to enter employee name
Position: Click here to enter Position
Department: Click here to enter Department
Facility: Click here to enter Facility
Date Conference Held (if applicable): Click here to enter a date.
1. VIOLATION: Statement of the problem. Facts include: Who, What, When, Where and How. Describe the violation of rules, policies, procedures, practices, Agency or regulatory standards, or unsatisfactory job performance.
Click here to enter Violation
2. PRIOR DISCUSSION OR WARNINGS: Prior documentation or discussion on this issue or related subject. This includes any supervisory action: effects of employee behavior on persons served, co-workers, department, Agency; and employee behavior. Documentation cited may include supervisory comments from prior Performance Evaluation, Employee Communication C-17, Conference Record C-411, Critical Incident Log C-101, Memorandum, conversation with employee, date(s) of receipt of information such as Personnel Policies Handbook, and applicable training such as NEO Personnel Policies, etc.
Click here to enter Prior Discussion or Warnings
3. STATEMENT OF AGENCY POLICY: Cite all Agency policies or procedures that were violated.
Click here to enter Statement of Agency Policy
4. CORRECTIVE ACTION: Summary of corrective action to be taken or that was taken. This may include a description of what is expected on the job in the future. List any target dates for improvement and dates that follow up will occur, if applicable.
Click here to enter Corrective Action
5. FAILURE TO MEET PERFORMANCE EXPECTATIONS: Consequences of failure to improve performance or correct behavior. Action that will be taken if employee does not meet objectives or change behavior.
Click here to enter Performance Expectations
COMPLETED BY (name and title): Click here to enter Name and Title
DATE: Click here to enter a date.
EMPLOYEE SIGNATURE BELOW INDICATES THAT THE EMPLOYEE HAS READ AND DISCUSSED THIS EMPLOYEE COMMUNICATION.
I have read and discussed this report:
Employee’s Signature Date
EMPLOYEE’S REMARKS: The employee may take the opportunity to provide remarks, comments, or a statement regarding this employee communication. Any written remarks, comments, or a statement will be forwarded to the employee’s personnel file.
EMPLOYEE SIGNATURE: DATE:
SUPERVISOR’S SIGNATURE: DATE:
ORIGINAL TO EMPLOYEE PERSONNEL FILE
Form C‑17 Rev. 4/84; 11/86; 7/89; 1/90; 12/91; 8/92; 8/93; 10/94; 1/99; 11/00, 3/09; 9/13 ; 10/13 Page 1 of 3